Croston Park Nursing Home on Town Road, Croston, Leyland, gave Janice Mary Powell her medicine incorrectly due to staff ignorance about an NHS red patient safety alert never to use a syringe to extract insulin from insulin pens and a lack of suitable needles.
But Area Coroner Richard Taylor was advised this did not contribute to Janice’s death in the Royal Preston Hospital on September 17, 2020. Janice, 68, died from sepsis caused by a urinary tract infection. Diabetes and heart failure also contributed to her death.
Shortfalls in the home’s care and issues with Royal Preston Hospital’s discharge of patients procedure were revealed during the hearing.
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The court was told Janice had spent many weeks in the hospital following a below the knee amputation and was discharged to Croston Park over the late August Bank Holiday weekend, with a supply of insulin pens but no needles to use with them and no care plan. The medications came unboxed without advice leaflets, although advice is also available online.
During the five hour inquest Simon Hill from the Care Quality Commission said: “The home must not use syringes to remove insulin from pens. There’s clear alerts on that. The hospital should have/must supply equipment to do it.”
Home manager Debbie Lewis said neither she nor other nurses had been aware of the alert.
Janice needed two types of insulin and both medicines were administered inappropriately at the home, but the overdosing related to just one, a concentrated medication called Toujeo.
During the inquest Janice’s family repeatedly asked about the impact mismedication would have had. Her son Stephen noted a Care Quality Commission report following a visit to the home last December detailed further concerns about the home’s administration of medicines. At one point he had to leave the room in distress.
Janice was first over, and then, after the home sought further advice, under medicated and had suffered glycaemic episodes.
Jessica Brown from Lancashire County Council’s safeguarding service said there had been neglect and acts of omission at the home and the local GP surgery had delayed providing needles when requested by the home. There had also been “learning” for the diabetic team and hospital ward and for the local CCG (Clinical Commissioning Group) to share patient safety alerts appropriately and often.
Janice was readmitted to RPH after becoming unwell at the nursing home and died the following day. The coroner said he felt he must give a narrative conclusion detailing the fact she was misadministered her medication.
He noted that following her discharge from hospital insulin medication was initially inappropriately administered at her nursing home for a number of days before she was readmitted to hospital with an infection on September 16.
Since her death there have been extensive changes in practice at both the care home and RPH.
Andrew Shepherd, a Croston Park director said: ”We constantly want to improve. If we can’t learn from incidents like this we shouldn’t be operating.” Stephen’s partner Nicola Ross, a nurse at RPH, said Janice had been looking forward to having a prosthetic limb fitted and had a lot to live for.